Provider Demographics
NPI:1750502829
Name:DEPTMENT OF JUVENILE SERVICES
Entity Type:Organization
Organization Name:DEPTMENT OF JUVENILE SERVICES
Other - Org Name:GREEN RIDGE YOUTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR-CLINICAL SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-478-3069
Mailing Address - Street 1:10700 15 MILE CRK ROAD
Mailing Address - Street 2:
Mailing Address - City:FLINTSTONE
Mailing Address - State:MD
Mailing Address - Zip Code:21530-3038
Mailing Address - Country:US
Mailing Address - Phone:301-478-3069
Mailing Address - Fax:301-478-3009
Practice Address - Street 1:10700 15 MILE CRK ROAD
Practice Address - Street 2:
Practice Address - City:FLINTSTONE
Practice Address - State:MD
Practice Address - Zip Code:21530-3038
Practice Address - Country:US
Practice Address - Phone:301-478-3069
Practice Address - Fax:301-478-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health